Health Differences: Nutrition

Essentials of Healthcare: Health Differences

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This a youtube lecture covering the required reading for Ch. 36 of Taylor's Fundamentals of Nursing. The lecturer's tone is a little dry but she does cover the entire chapter.

Fundamentals of Nutrition

Chapter 36, Nutrition
Outline

1. Nutrition- the study of nutrients and how they are handled by the body, as well as the impact of human behavior and environment on the process of nourishment
2. Nutrient- specific biochemical substance used by the body fro growth, development, activity, reproduction, lactation, health maintenance, and recovery from illness/injury
3. Essential Nutrient- must be provided in the diet or through supplements because they are not synthesized in the diet
4. Basal Metabolism- the energy required to carry on the involuntary activities of the body at rest, the energy needed to sustain the metabolic activities of cells and the tissues.

These activities include:

1.maintaining body temp and muscle tone

2.producing and releasing secretions

3.propelling food through GI tract

4.inflating lungs

5.contracting heart muscle

BMR= 1cal/kg/hr (men) 0.9cal/kg/hour (women)

Factors that increase BMR:

1.growth

2.infection

3.fever

4.emotional tension

5.extreme environmental temps

6.increased levels of certain hormones (epi & thyroid)

Factors that decrease BMR:

1.age

2.prolonged fasting

3.sleep

5. Body Mass Index: preferred method to establish ideal body weight. A ratio of weight (kg) to height (meters). Reliable indicator of total fat stores. Does not change according to gender. Provides relative estimation of risk for heart disease, diabetes, and hypertension

1lb of body fat = ~ 3500 cal

6.Carbohydrates- sugars and starches. Organic compounds composed of carbon, hydrogen, and oxygen. The only animal source of carb is lactose.

a. As income increases, carb intake decreases, and protein increases.

b. Classified as simple (mono, disaccharide)  or complex (polysaccharide)

c. All carbs are converted to glucose for transport the blood or for use as energy. Glucose is transported through the GI tract, through the portal vein, to the liver, where it is stored. 

1. Hormones for glucose regulation- Insulin and Glucagon

1. Glycogenisis- glucose is converted to glycogen and stored

f. Glycogenolysis- glycogen is broken down back into glucose for use 

1. Primary function of carbs is to provide energy                                                                                                           Carbs provide 4cal/gram regardless of the source 

7. Ketosis- an abnormal accumulation of ketone bodies that is frequently associated with acidosis. At least 50-100grams of carbs are needed daily to prevent ketosis. Carbs should provide 46-65% total calories.

8.Protein- a vital component of every living cell; combined of carbon, hydrogen, nitrogen, and oxygen. They are required for the formation of all body structures including genes, enzymes, muscle, bone matrix, skin, and blood.

9. Complete proteins contain sufficient amounts and proportions of all the essential amino acids to support growth whereas incomplete proteins are deficient in one or more essential amino acid.

Examples of complete proteins: animal proteins (eggs, dairy, meat)

Examples of incomplete proteins: plant proteins (grains, legumes, veggies)

-Soy is a complete protein

Dietary protein is broken down into amino acid particles by pancreatic enzymes in the small intestine. These are absorbed through the intestinal mucosa to be transported to the liver. In the liver, amino acids are recombined into new proteins or are released into the bloodstream for use in protein synthesis by tissues and cells. Excess amino acids are converted to fatty acids, ketone bodies, or glucose, and are stored or used as metabolic fuel.

Positive nitrogen balance- Nitrogen intake > excretion.

Negative nitrogen balance- Nitrogen excretion < ingestion

This occurs during starvation and immediately following surgery, illness, trauma,  and stress.

The a major function of protein is to maintain body tissues that break down from  normal wear and tear and to support the growth of new tissue.

Protein can be oxidized to provide 4cal/gram

Recommended daily intake- 0.8g/kg of desired body weight

10. Lipids- group name for fatty substances, including fats, oils, waxes, and related compounds. Lipids are insoluble in water and insoluble in the blood.

11. Triglycerides- compose 95% of lipids in the diet. Predominant form of fat in food and the major storage form of fat in the body 

Fats are saturated or unsaturated depending on the amount of hydrogen in fat  molecules.

Animal fats- saturated

Vegetable fats- unsaturated (oils)

12. Trans fat- fat that occurs when manufacturers partially hydrogenate liquid oils so that they become more solid and stable. Trans fat raises serum cholesterol.

13. Cholesterol- fat like substance found only in animal products. Important component of cell membranes. Abundant in brain and nerve cells. Used to synthesize bile acids and is a precursor of the steroid hormones and vitamin D.

High serum levels of cholesterol are associated with increased risk for  atherosclerosis.

Increasing fiber increases fecal excretion of cholesterol.

Fat digestion occurs in the small intestine. Bile, secreted by the gallbladder,  emulsifies fat to be broken down by pancreatic lipase.

Fat provides 9cal/gram

Fats increase the palatability of the diet. Fat has a high satiety value because it  delays gastric emptying time.

Fat aids in absorption of fat soluble vitamins and provides insulation, structure,  and temperature control.

11. Vitamins- organic substances needed by the body in small amounts to help regulate body processes; are susceptible to oxidation and destruction. They are needed for the metabolism of energy nutrients.

The absence or insufficient use of vitamins in the body causes specific deficiency syndromes. 

Vitamins are classified as either fat soluble or water soluble.

Water soluble (C and B’s) are absorbed directly into the bloodstream and are not stored in the body. Excess is   

excreted in the urine.

Fat soluble vitamins (A,D,E,K) must attach to protein for transport.

Secondary deficiencies of fat soluble vitamins can occur anytime there is na alteration in fat digestion or absorption (i.e. during malabsorption syndromes and pancreatic and biliary disease.)

The body stores excess fat soluble vitamins in the liver and adipose tissues, thus a daily intake is not necessary. And deficiency syndromes may take weeks, months, or years to develop.

Supplements may be useful when they fill a specific, identified, nutrient gap that cannot, or is not otherwise being met, by the individuals intake of food. (NIH, 2007). Supplements can however, ensure the adequate intakes of specific nutrients because of physiologic limitations or changes.

Example: When given during pregnancy, folate supplementation has significantly decreased the risk of children with neural tube defects.

12.  Minerals- inorganic compounds found in the body fluids and tissues in the form of alts (sodium chloride) or combined with organic compounds (iron in hemoglobin)

Macrominerals- need >100mg/day

Microminerlas- need < 100mg/day

13. Water- accounts for 50-60% of adult's total weight

                  2/3 in ICF, 1/3 in ECF (ECF includes plasma and interstitial tissue)

Sources of water in the diet are: beverages

                                                    food

                                                    metabolism of carbs, protein, and fat

Water leaves the body via: urine

                                           feces

                                           expired air

                                           persperation

Adult H20 intake- 2-3,000ml/day

14.Digestion- the break down of food into particles small enough to pass into the cells and to be used by the cells

15. Infants:

• birth to one year, most rapid growth period
• birth weight doubles by 4-6 months, triples by 1 year
• length increases 50%

• Iron stores present at birth start to become depleted between 3-4 months
• Immune system matures, 4-6 months

• If infant is not breastfed, infant should receive iron fortified formula. Cow's milk is not recommended for infants < 1 year of age.           

Regular unmodified cow's milk is not suitable for infants because:

1. it causes GI bleeding
2. it's renal solute load is too concentrated for the infant's renal system to handle making it too difficult to maintain fluid balance, especially during times of illness, diarrhea, or hot weather
3. early expose to cows milk increases the risk of developing allergies to milk proteins
4. it adversely affects nutrition status. Cow's milk is low in iron and iron status in the infant is lowered even further by the associated GI bleeding. In addition, cow's milk makes a poor source of vitamins C and E and essential fatty acids. Infants have need for fat; thus they should not be fed reduced fat milks such as nonfat or 2% fat. Low fat or not fat milks do not provide 1) sufficient energy to support growth requirements, easing the infant to consume increased volumes of milk and excessive protein, and 2)sufficient linoleum acid, the essential fatty for growth and development. (Essentials of Nutrition and Diet Therapy, 10th edition, pg 270-271)

*To meet the special needs of infants, the AAP recommends breast milk or formula as the major food source up to 1 year of age, with gradual addition addition of appropriate foods beginning at 6-7 months.


16. Toddlers and Preschoolers

• growth rate slows
• 3-5 year develops attitudes about food
• they can feed themselves, verbalize likes and dislikes, use food to manipulate parents
• appetite dramatically decreases
• decreased intake of fruits and veggies
• increased intake of sweetened fruit drinks

17. School Aged Children

• 6-12 years old
• uneven, individualized, erratic growth pattern
• increasing energy requirements need food of high nutritious value
• parents role of primary food regulator diminishes and advertising has impact on food choices

18. Adolescents 

• rapid physical, emotional, social, and sexual maturation
• Eating disorders and poor diet practices

1. anorexia
2. bulemia
3. fasting
4. diet pills
5. laxatives

19. State of Health

• fevers increase the need for fluid and calories
• Trauma (surgery, burns) affect body's use of nutrients
• Mental health- may forget to eat
• Chronic disorders- (diabetes, renal disease, hypertension, heart disease, GI d/o's cancer) can influence nutrient intake, digestion, metabolism, excretion

20. Obesity- defined as body weight 20% or more above ideal or a BMI > 30

21. Nutritional Screening-  DETERMINE

22. Dysphagia- difficulty or inability to swallow

23 Liquid Diets-  used most often as transitional diets when eating resumes after illness, surgery, or parenteral nutrition

• clear liquid, full liquid, soft diet, normal

24. NPO- (per book) pt's that are NPO for > 2 days will require enteral or parenteral support

25. NG- through nose and into stomach, puts pt's at risk for aspiration

              The following are not candidates for NG: 

               1. dysfunctional gag

               2. high risk for aspiration

               3. gastric stasis

               4. reflux

               5. nasal injuries

               6. those unable to elevate the head of bed during feedings

Types fo NG tubes:

• Levin- thicker, firmer
• Dobhoff- smaller, more pliable, less traumatic but more difficult to check tube placement and administer meds

26. NI Tube- passed though the nose and into the upper portion of the small intestine. Better for patients with high risk for aspiration, diminished gag reflex, or slow gastric motility

* When formula is delivered directly into the intestine, a type of dumping syndrome may develop because the pyloric valve in the stomach, which normally slows the transit of food into the intestine, is bypassed. Rapid administration of hypertonic feeding solution into the proximal small intestine causes the movement of extracellular fluid from the vascular system into the small intestine. Distention of the small intestine occurs with accompanying gas, nausea, diarrhea, cramping, and lightheadedness.

Verifying Feeding Tube Placement:

When to confirm placement:

• after initial insertion
• before beginning feeding or instilling liquids
• at regular intervals during continuous feeds

The purpose is checking placement is to make sure the tip is situated in the stomach  or intestine- to prevent meds from going to the wrong place (lungs...aspiration)

Methods of checking tube placement:

• radiographic examination
• aspirate pH
• visual assessment of aspirate
• measurement of tube length and tube marking
• monitoring CO2
• ***Auscultation  of air injected into tube has proven to be unreliable and should not be used (AACN, 2005)

Radiographic Conformation

• standard procedure for initial placement
• Cons: must be read by MD, costly (when done repeatedly), might not have access to frequent x-ray

Measurement of aspirate and visualization of aspirate

• recommended method
• less helpful during continuous feeds because formula acts as buffer
• smaller tubes more likely to collapse due to negative pressure exerted during aspiration of contents
• if there is resistance, tube often is blocked
• if you do not aspirate contents, tube may not be in fluid
• ***If repeated instillations of 30ml of air and repositioning do not help, get x-ray

Measurement of tube Length and Marking

• measure length of exposed tube when initially placed, compare
• mark tube at nostril when placed

CO2 Monitoring 

• using capnograph or calorimetric end tidal CO2 detector check for presence of CO2. If CO2 is detected, tube is in airway, not stomach

NI Tube placement confirmation

• check pH aspirate
• should be pH >7 and bile stained
• can range in color from light golden yellow to brownish green

Long Term Nutritional Support

• enterstomal tube placed through opening into stomach or jejunum
• Placed via PEG- surgically or laproscopically placed g-tube (text is somewhat confusing, will clarify)

PEG

• does not require general anesthesia
• requires a functioning GI tract 

Long term feeding for pt's with gastric problems requires a jejunostomy

LPGD (pow profile gastric device)

• button or skin disk
• no external tubing
• good for active patients and children
• easy to conceal
• can be immersed in water

Checking placement of G/J tubes

• compare measurement

Tube Feeding Administration

nutritionist makes recc's

Continuous Feeds:

• allows for gradual introduction of the formula into the GI tract
• promotes maximal absorption
• requires use of enteral feeding pump
• limits pt mobility
• increases cost
• ***continuous feeds in to the stomach are controversial because of increased risk for aspiration and refuel

*Feeds into the intestine are ALWAYS continuos to avoid dumping syndrome

Intermittent Feeds:

• are preferred at regular intervals and in equal portions
• formula should be introduced gradually via gravity or feeding pump 
• Bolus may place pt at risk for aspiration or cause distention. Usually not recommended.
• intermittent feeds resemble a more normal pattern of intake and allow the pt mobility

Cyclic Feeding

• cont feeds for 12-16 hours, usually at night, to allow the to attempt to eat a meal during the day

ENTERAL FEEDING

Nutritional Composition of Formula Depends On:

• feeding route
• pts ability to absorb and digest the nutrients
• pts own fluid and nutrient requirements

Other considerations when selecting formula:

• availability and cost of formula
• medical conditions that require diet modification
• food  intolerance
• allergies

Standard Formulas:

• contains intact molecules of protein, carbs, and fats and require pt to have normal digestion and absorption

Hydrolyzed Formulas

• contain protein and other nutrients in simple forms that require little or no digestion
• can be used for pt with impaired digestion or absorption 

Most formulas contain 1cal/ml, 2 cal/ml is available. If you are unsure of calorie content, check product label

Initiating Feeds:

• start with full strength
• 10-40m/hr depending on institutional policy
• advance rate by 10-20 ml/hr q8h until desired rate achieved
• desired rate confirmed by pt tolerance

Criteria for evaluating tolerance:

• absence or nausea, vomiting
• minimal or no gastric residual
• absence or abdominal pian, distention
• presence of bowel sounds wnl

Enteral Feeding Pump:

• pump regulates amount of formula going to pt
• newer pumps have safety features
• can be used in home or hospital
• should be plugged into power source when pt is not mobile

Nursing Considerations for Pt with Tube Feedings:

• follow policies of your institution
• patient safety
• monitor for complications
• comfort
• education

To Promote Pt Safety be Mindful of the Following:

• check tube placement before administering fluids, meds, or feeds using multiple methods
• check residual before each feed or q4-6 during continuous feeds
• high gastric residual volume increases risk for aspiration or aspiration pna 
• residual of >10-20% above hourly rate may indicate feed should be dc'd or delayed
• flush w water after checking residual to prevent occlusion 
• access abdomen for abnormalities
• assess bowel sounds at least q shift for presence of peristalsis and functioning GI tract
• ***do not delay feeds based solely on hypoactive bowel sounds in acutely ill pts
• make sure pt is upright 30 degrees
• maintain integrity of system and use proper technique to avoid contamination
• open system- when can or bottle formula is added to feeding setup
• clean reusable system q24h
• meds may be given via tube but never while a med is being infused
• never add meds directly to formula
• flush tube before, between, and after
• meds may become ineffective or clog tube if mixed with formula

Providing Instruction:

• give edu on administration, how to use pump, formula, instructions re rate, how to check tube placement, what to do if tube becomes dislodged
• how to care for insertion site and complications
• preparation, cleaning, disposal of equipment
• emergency #'s, home health agency #, and MD #
• arrangements for follow up care from home health nurse

Removal of NG:

• remove as carefully as inserted
• provide extensive oral hygiene as tube has been in contact with GI tract and intestinal contents

NG Tubes for Decompression (other uses for NG):

• decompress or drain stomach of fluid or unwanted stomach contents
• to monitor GI bleeding
• to prevent intestinal obstruction

PARENTERAL NUTRITION- the administration of nutrition support via IV route

For pt's who:

• cannot meet nutritional needs via oral or enteral route
• pts that have nonfunctioning GI tracts
• who are comatose
• have high caloric and nutritional needs due to illness/injury
• pts undergoing aggressive cancer therapy
• those recovering from extensive burns, surgery, or sepsis
• can be administered through central venous access device (TPN) or peripherally (PPN), the major difference between TPN and PPN is concentration

Total Parenteral Nutrition: meets the needs by way of nutrient filled solutions delivered via central venous access device

• highly concentrated
• hypertonic nutrient solution
• provides calories
• restores nitrogen balance
• replaces essential fluids, electrolytes, minerals, and trace elements
• can promote tissue and would healing and normal metabolic function
• provides bowel a chance to heal
• reduces activity in gallbladder, pancreas, and small intestine
• may be used to improve pt response to surgery
• sometimes called hyperaliminatiton 

Assessment Criteria to determine the need for TPN:

• inability to absorb nutrients grom GI tract for >10 days
• presence of debilitating illness lasting > 2 weeks
• loss of 10% or more of pre-iness weight
• serum albumin > 3.5g/dL
• excessive nitrogen loss from wound infection, fistula, or abcess
• renal or hepatic failure
• non functioning GI tract for 5-7 days

Peripheral Parenteral Nutrition (PPN):

• less concentrated nutrient solution
• for pts needing short term nutritional support, < 2 weeks
• administered through peripheral vein
• veins cannot tolerate highly concentrated solutes, so it is not as nutrient dense as TPN

PARENTERAL NUTRITION SOLUTIONS

TPN:

• hypertonic
• 3 primary components: proteins, carbs, fats
• additional components: electrolytes, vitamins, trace elements
• tailored to meet each individual pts needs
• fat or lidid emulsions and dextrose add caloric value
• ***because of the high glucose concentration (~25%), it is important to monitor blood glucose levels

PPN:

• isotonic
• contain components similar to TPN but in smaller amounts
• low concentrations of dextrose and amino acids
• provide fewer calories and supplement a pts oral intake
• contains ~10% glucose which is suitable for administration into a peripheral vessel

PARENTERAL FEEDING COMPLICATIONS:

• costly
• requires constant monitoring
• has potential for causing infections and metabolic complications
• complications related to the use of central venous access devices, such as pneumothorax and thromboembolism, 
• infections and sepsis
• metabolic alterations (ie, hyper/hypoglycemia)
• fluid, electrolyte, and acid-base imbalances
• phlebitis
• hyperlipidemia\liver and gallbladder disease

Parenteral Nutrition in Home Setting, Pt education should include:

• basic info about TPN
• adverse reactions or catheter complications
• when to contact MD
• care of venous access device
• maintenance of equipment
• frequency for measuring the patient's weight, intake and output, and monitoring glucose

Evaluating Effectiveness:

• evaluate pts progress towards meeting nutritional goals
• evaluate pts tolerance and adherence to the diet
• assess pts level of understanding of the diet and assess need for further education
• communicate findings to other members of healthcare team
• revises plan of care, as needed, or terminates nursing care

Guidelines for Monitoring Administration of Parenteral Nutrition: (Taylor's, pg 1196)

• use the same catheter for administration of parenteral nutrition each time tube is changed
• use a pump to administer infusion of nutrition
• if administration of nutrition is interrupted, administer a 5-10% dextrose solution to prevent hypoglycemia, based on facility policy
• discard unused solution within 24h of starting its administration
• check vitals q4h to monitor for signs of infection or sepsis
• monitor blood glucose levels q6h
• use aseptic techniques when changing administration materials. most rec changing q24h.
• change dressings at least three times a week, per institutional protocol. Change if they become wet, soiled, or non occlusive
• check that all connections are securely taped, catheter is clamped before opening system, and insertion site is covered with sterol dressing
• compare the pts daily weight to fluid intake and output. total weight gain should not be more than 3 lbs/week. weight gain > 1 lb/day indicates fluid retention
• assess serum protein and electrolyte evils for sign of an imbalance
• because of high glucose concentration, use tubing with an inline filter